Communication Authorization/Family Dynamic Form

Family Readiness and Deployment Support begins with the ability to communicate with the family, friends and identified persons that are important to you, the Sailor. Please complete this form and return to the Ombudsman/CSC no later than _____/_____/2012. Privacy Statement: The Ombudsman is bound by the Privacy Act of 1974 and as such all Personally Identifiable Information or PII is protected, securely stored and will be kept confidential. Further, the Ombudsman is bound by a confidentiality code of ethics.

Sailors INFO
Last Name

First Name

Rank/Rate/Department

City

PRD (mm/dd/yy)

State

Street Address Personal Email Address

Married Status:

Children:

Zip

SSN Last 4

Number:

Single

Married

Divorced

Yes

No

Communication Authorization
Without your authorization the Ombudsman cannot provide information to those your love. Please provide contact information for family and friends that you want to be included in the various communication streams. When completing this form consider these types of communication and those you want included:

1)
SOs

Family info regular emails with resources, command information, opportunities and more. Primarily for spouses, children, Newsletter monthly eNewsletter with information on the command, FRG, events, resources and opportunities. Appropriate

2)
for all.

3)

Inquiries/Support calls/emails TO THE OMBUDSMAN from those who love you. Who do you want the Ombudsman to provide wellness info? The Ombudsman is only authorized to give your loved ones limited info such as, Yes, ship has been busy, and, yes, your sailor is fine. We want to serve you in providing peace of mind to those you authorize. These are also those that you want the Ombudsman to offer further support (referrals, etc.) 4) Facebook/Twitter updates who do you want to be able to connect with and have access to the Ombudsman/Command social media streams? 5) Emergency or Important Information Who do you want to receive official command communication about schedule changes (early return, deployment extension, etc.). Please use this key to complete form:

Relationship Key: S=Spouse P=Parent GP= Grandparent OF=Other Family SO= Significant Other
Last Name

C=Child

AC=Authorized Contact

First Name

City

Relationship

S
St Email #2 Zip

GP All

OF 1

SO 2 3

C 4

AC 5

Street Address Email # 1 Cell Phone Number

Carrier (i.e. Verizon)

Communication Authorized

Work Phone Number

Last Name

First Name

City

Relationship

S
St Email #2 Zip

GP All

OF 1

SO 2 3

C 4

AC 5

Street Address Email # 1 Cell Phone Number

Carrier (i.e. Verizon)

Communication Authorized

Work Phone Number

Communication Authorization/Family Dynamic

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For Official Use Only

Communication Authorization/Family Dynamic Form (contd)

Relationship Key: S=Spouse P=Parent GP= Grandparent OF=Other Family SO= Significant Other C=Child AC=Authorized Contact

Communication Key: 1= Family Email 2=Newsletter 3=Inquiries/Support 4=Social Media 5=Official/Emergency Communication
Last Name

First Name

City

Relationship

S
St Email #2 Zip

GP All

OF 1

SO 2 3

C 4

AC 5

Street Address Email # 1 Cell Phone Number

Carrier (i.e. Verizon)

Communication Authorized

Work Phone Number

Last Name

First Name

City

Relationship

S
St Email #2 Zip

GP All

OF 1

SO 2 3

C 4

AC 5

Street Address Email # 1 Cell Phone Number

Carrier (i.e. Verizon)

Communication Authorized

Work Phone Number

Last Name

First Name

City

Relationship

S
St Email #2 Zip

GP All

OF 1

SO 2 3

C 4

AC 5

Street Address Email # 1 Cell Phone Number

Carrier (i.e. Verizon)

Communication Authorized

Work Phone Number

Last Name

First Name

City

Relationship

S
St Email #2 Zip

GP All

OF 1

SO 2 3

C 4

AC 5

Street Address Email # 1 Cell Phone Number

Carrier (i.e. Verizon)

Communication Authorized

Work Phone Number

Last Name

First Name

City

Relationship

S
St Email #2 Zip

GP All

OF 1

SO 2 3

C 4

AC 5

Street Address Email # 1 Cell Phone Number

Carrier (i.e. Verizon)

Communication Authorized

Work Phone Number

Communication Authorization/Family Dynamic

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For Official Use Only

Family Dynamic Sheet

Please complete the following form to enable the Ombudsman and Family Readiness Team support you and your family throughout the seasons of military life while assigned to MCM Crew Constant. Privacy Statement: The Ombudsman is bound by the Privacy Act of 1974 and as such all Personally Identifiable Information or PII is protected, securely stored and will be kept confidential. Further, the Ombudsman is bound by a confidentiality code of ethics. Spouse/Significant Other Name Relationship Spouse City Date of Birth (mm/dd) Significant Other Anniversary (mm/dd)

State

Zip

Address if not listed above

Children:
Childs Name Son if same as above City Daughter Birthday ( MM/DD/YYY)

Address

Son Daughter

State

Birthday ( MM/DD/YYY)

Zip

Childs Name Address if same as above

City

State

Birthday ( MM/DD/YYY)

Zip

Childs Name

Son if same as above City

Daughter

Address

State

Birthday ( MM/DD/YYY)

Zip

Childs Name

Son if same as above City

Daughter

Address

State

Birthday ( MM/DD/YYY)

Zip

Childs Name

Son if same as above City

Daughter

Address

State

Birthday ( MM/DD/YYY)

Zip

Childs Name

Son if same as above City

Daughter

Address

YES

State

Zip

Do you have other dependents (i.e. parent, stepchildren, etc)?

NO If Yes, please give details. ________________________

_________________________________________________________________________________________________________________________ Are you expecting? YES NO If Yes, please give due date: __________________________

Anything else you would like the Ombudsman to know to more fully support your family? (i.e., ill parent, EFMP family member, etc) _ __________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________

Communication Authorization/Family Dynamic

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For Official Use Only